  <form name=form1 action="{REQUEST_URI}" method="post">
    <input type="hidden" value="{amount}" name="amount">
	<input type="hidden" value="{item_name}" name="item_name">
	<input type="hidden" value="{currency_code}" name="currency_code">
	<input type="hidden" value="{return}" name="return">
    <div id=title>
      <div id=title_header>Billing Information</div>
      <div id=title_instructions>Please complete payment info below and click continue.</div>
    </div>
    <!-- This products div is not required if you have a page before this that shows them total charges -->
    <p style="color: #FF0000;font-weight: bold;">{error}</p>
    <div id=products>
      <div id=products_header>&nbsp;&nbsp;Items in Cart</div>
      <div id=products_body>
        <ul id="products_list">
          <li>1 - {item_name} @ {currency_code} {amount} 			
        </ul>
      </div>
    </div>
    <div id=payment_types>
      <div id=payment_types_header>&nbsp;&nbsp;Payment Method</div>
      <div id=payment_types_body>
        <input type="Radio" name="payment_method" value="dcc" checked >
  &nbsp; <img src="{img_path}logo_ccVisa.gif" alt=" Visa" width="37" height="21" border="0"> <img src="{img_path}logo_ccMC.gif" alt=" Mastercard" width="37" height="21" border="0"> <img src="{img_path}logo_ccDiscover.gif" alt=" Discover" width="37" height="21" border="0"> <img src="{img_path}logo_ccAmex.gif" alt=" American Express" width="37" height="21" border="0"><br>
      </div>
    </div>
    <div id=cc_info>
      <div id=cc_info_header>&nbsp;&nbsp;Credit or Debit Card Information</div>
      <div id=cc_info_body>
        <input value="Sale" type="hidden" name="PaymentAction">
        <input type="hidden" value="1.00" name="ItemTotal">
        <input type="hidden" value="0.00" name="TaxTotal">
        <input type="hidden" value="Direct Payment" name="OrderDescription">
        <table class=table_class>
          <tr class=tr_class>
            <td class=td1_class>&nbsp;</td>
            <td class=td2_class colspan=2>&nbsp;</td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Credit Card Type: </td>
            <td class=td2_class colspan=2><select name="CreditCardType">
                <option value="Visa">Visa</option>
                <option value="MasterCard">MasterCard</option>
                <option value="Discover">Discover</option>
                <option value="American Express">American Express</option>
              </select>
            </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Credit Card Number: </td>
            <td class=td2_class colspan=2><input name="CreditCardNumber" value="4983599115150124" autocomplete=off size="20">
            </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Security Code: </td>
            <td class=td2_class colspan=2><input name="CVV2" value="000" autocomplete=off size="5">
              (last 3 digit # on back of card) </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Exipration Date: </td>
            <td class=td3_class><select name="ExpMonth">
                <option value="1">01</option>
                <option value="2">02</option>
                <option value="3">03</option>
                <option value="4">04</option>
                <option value="5">05</option>
                <option value="6">06</option>
                <option value="7">07</option>
                <option value="8">08</option>
                <option value="9">09</option>
                <option value="10">10</option>
                <option value="11">11</option>
                <option value="12">12</option>
              </select>
            </td>
            <td class=td4_class><select name="ExpYear">
                <option value="2006">2006</option>
                <option value="2007">2007</option>
                <option value="2008">2008</option>
                <option value="2009">2009</option>
                <option value="2010">2010</option>
                <option value="2011">2011</option>
                <option value="2012">2012</option>
                <option value="2013">2013</option>
                <option value="2014">2014</option>
                <option value="2015">2015</option>
              </select>
            </td>
          </tr>
        </table>
      </div>
    </div>
    <div id=coupon_info>
      <div id=coupon_info_header>&nbsp;&nbsp;Gift Certificate or Coupon Code</div>
      <div id=coupon_info_body>
        <table class=table_class>
          <tr class=tr_class>
            <td class=td1_class> Coupon Code </td>
            <td class=td2_class colspan=2><input type="Text" name="CouponCode" size="20">
            </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Gift Certificate Number </td>
            <td class=td2_class colspan=2><input type="Text" name="GiftCertificate" size="20">
            </td>
          </tr>
        </table>
      </div>
    </div>

    <div id=billing_address>
      <div id=billing_address_header>&nbsp;&nbsp;Billing Address</div>
      <div id=billing_address_body>
        <table width="602" class=table_class>
          <tr class=tr_class>
            <td width="127" class=td1_class>&nbsp;</td>
            <td width="431" colspan=2 class=td2_class>&nbsp;</td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> First Name </td>
            <td class=td2_class colspan=2><span class="inner_td1_class">
              <input name="BillingFirstName" size="20" value="{BillingFirstName}">
            </span></td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class>Last Name</td>
            <td class=td2_class colspan=2><span class="inner_td1_class">
              <input name="BillingLastName" size="20" value="{BillingLastName}">
            </span></td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Street </td>
            <td class=td2_class colspan=2><input name="BillingStreet1" size="20" value="{BillingStreet1}">
            </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Street 2 </td>
            <td class=td2_class colspan=2><input name="BillingStreet2" size="20" value="{BillingStreet2}">
            </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> City </td>
            <td class=td2_class colspan=2><span class="inner_td1_class">
              <input name="BillingCityName" size="20" value="{BillingCityName}">
            </span></td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class><span class="Style4">State or Province</span></td>
            <td class=td2_class colspan=2>
              <select name="BillingStateOrProvince">
                <option value=""></option>
                <option value="AK">AK</option>
                <option value="AL">AL</option>
                <option value="AR">AR</option>
                <option value="AZ">AZ</option>
                <option value="CA">CA</option>
                <option value="CO">CO</option>
                <option value="CT">CT</option>
                <option value="DC">DC</option>
                <option value="DE">DE</option>
                <option value="FL">FL</option>
                <option value="GA">GA</option>
                <option value="HI">HI</option>
                <option value="IA">IA</option>
                <option value="ID">ID</option>
                <option value="IL">IL</option>
                <option value="IN">IN</option>
                <option value="KS">KS</option>
                <option value="KY">KY</option>
                <option value="LA">LA</option>
                <option value="MA">MA</option>
                <option value="MD">MD</option>
                <option value="ME">ME</option>
                <option value="MI">MI</option>
                <option value="MN">MN</option>
                <option value="MO">MO</option>
                <option value="MS">MS</option>
                <option value="MT">MT</option>
                <option value="NC">NC</option>
                <option value="ND">ND</option>
                <option value="NE">NE</option>
                <option value="NH">NH</option>
                <option value="NJ">NJ</option>
                <option value="NM">NM</option>
                <option value="NV">NV</option>
                <option value="NY">NY</option>
                <option value="OH">OH</option>
                <option value="OK">OK</option>
                <option value="OR">OR</option>
                <option value="PA">PA</option>
                <option value="RI">RI</option>
                <option value="SC">SC</option>
                <option value="SD">SD</option>
                <option value="TN">TN</option>
                <option value="TX">TX</option>
                <option value="UT">UT</option>
                <option value="VA">VA</option>
                <option value="VT">VT</option>
                <option value="WA">WA</option>
                <option value="WI">WI</option>
                <option value="WV">WV</option>
                <option value="WY">WY</option>
                <option value="AA">AA</option>
                <option value="AE">AE</option>
                <option value="AP">AP</option>
                <option value="AS">AS</option>
                <option value="FM">FM</option>
                <option value="GU">GU</option>
                <option value="MH">MH</option>
                <option value="MP">MP</option>
                <option value="PR">PR</option>
                <option value="PW">PW</option>
                <option value="VI">VI</option>
              </select>
           </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class><span class="Style4">Zip/Postal Code</span></td>
            <td class=td2_class colspan=2><span class="inner_td1_class">
              <input name="BillingPostalCode" maxlength="20" size="10" value="{BillingPostalCode}">
            </span></td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Country </td>
            <td class=td2_class colspan=2><select name="BillingCountry">
                <option value="US">United States</option>
                <option value="AI">Anguilla</option>
                <option value="AR">Argentina</option>
                <option value="AU">Australia</option>
                <option value="AT">Austria</option>
                <option value="BE">Belgium</option>
                <option value="BR">Brazil</option>
                <option value="CA">Canada</option>
                <option value="CL">Chile</option>
                <option value="C2">China</option>
                <option value="CR">Costa Rica</option>
                <option value="CY">Cyprus</option>
                <option value="CZ">Czech Republic</option>
                <option value="DK">Denmark</option>
                <option value="DO">Dominican Republic</option>
                <option value="EC">Ecuador</option>
                <option value="EE">Estonia</option>
                <option value="FI">Finland</option>
                <option value="FR">France</option>
                <option value="DE">Germany</option>
                <option value="GR">Greece</option>
                <option value="HK">Hong Kong</option>
                <option value="HU">Hungary</option>
                <option value="IS">Iceland</option>
                <option value="IN">India</option>
                <option value="IE">Ireland</option>
                <option value="IL">Israel</option>
                <option value="IT">Italy</option>
                <option value="JM">Jamaica</option>
                <option value="JP">Japan</option>
                <option value="LV">Latvia</option>
                <option value="LT">Lithuania</option>
                <option value="LU">Luxembourg</option>
                <option value="MY">Malaysia</option>
                <option value="MT">Malta</option>
                <option value="MX">Mexico</option>
                <option value="NL">Netherlands</option>
                <option value="NZ">New Zealand</option>
                <option value="NO">Norway</option>
                <option value="PL">Poland</option>
                <option value="PT">Portugal</option>
                <option value="SG">Singapore</option>
                <option value="SK">Slovakia</option>
                <option value="SI">Slovenia</option>
                <option value="ZA">South Africa</option>
                <option value="KR">South Korea</option>
                <option value="ES">Spain</option>
                <option value="SE">Sweden</option>
                <option value="CH">Switzerland</option>
                <option value="TW">Taiwan</option>
                <option value="TH">Thailand</option>
                <option value="TR">Turkey</option>
                <option value="GB">United Kingdom</option>
                <option value="UY">Uruguay</option>
                <option value="VE">Venezuela</option>
              </select>
            </td>
          </tr>
          <tr class=tr_class>
            <td class=td1_class> Phone </td>
            <td class=td2_class colspan=2><input name="BillingPhone" size="20" value="{BillingPhone}">
            </td>
          </tr>
        </table>
      </div>
    </div>
    <div id=submit>
      <input name="Pay" type="submit" id="Pay" value=" Continue ">
    </div>
  </form>